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Headache, Tension

Headache, Tension is a topic covered in the 5-Minute Clinical Consult.

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  • Typically characterized by bilateral mild to moderate pain and pressure; may be associated with pericranial tenderness at the base of the occiput
  • Two types
    • Episodic tension–type headache (ETTH) divided into
      • Infrequent: <1 day per month
      • Frequent: ≥1 but <15 days per month
    • Chronic tension–type headache (CTTH): ≥15 days per month for >3 months
  • Synonym(s): muscle contraction headache; stress headache


Most common type of primary headache

  • Global prevalence in adults is 42% (1).
  • Lifetime prevalence is 79%.
  • More prevalent among women
  • Prevalence of CTTH is 3%.
  • Prevalence of ETTH decreases with age, whereas the prevalence of CTTH increases with age.

Etiology and Pathophysiology

  • Debatable: peripheral and/or central mechanisms
  • Activation of peripheral nociceptors leads to muscle tenderness in ETTH.
  • Central sensitization is associated with CTTH:
    • Nitric oxide may play an important role in central sensitization.
    • Debatable: low-platelet serotonin
  • Peripheral: may provoke the central mechanism leading from ETTH to CTTH
  • Stress is the most frequently reported precipitating factor.

An increased genetic risk has been suggested by studies, particularly for CTTH.

Risk Factors

Associated with triggers/precipitating factors

  • Stress (mental or physical)
  • Change in sleep regimen
  • Skipping meals
  • Certain foods (caffeine, alcohol, chocolate)
  • Dehydration
  • Physical exertion
  • Environmental factors (sun glare, odors, smoke, noise, lighting)
  • Poor or sustained posture
  • Female hormonal changes
  • Medications (e.g., nitrates, SSRIs, antihypertensives)
  • Overuse of abortive headache medication

General Prevention

  • Identify and avoid triggers/precipitating factors.
  • Minimize emotional stress.
  • Encourage relaxation techniques:
    • Biofeedback, relaxation therapy, and physical therapy
    • Consider counseling/psychotherapy.

Commonly Associated Conditions

  • 83% of patients with migraine headaches also suffer from tension-type headaches.
  • Debatable: increased prevalence of comorbid anxiety and depression

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Stephens, Mark B., et al., editors. "Headache, Tension." 5-Minute Clinical Consult, 27th ed., Wolters Kluwer, 2019. Medicine Central, im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116255/all/Headache__Tension.
Headache, Tension. In: Stephens MB, Golding J, Baldor RA, et al, eds. 5-Minute Clinical Consult. 27th ed. Wolters Kluwer; 2019. https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116255/all/Headache__Tension. Accessed April 24, 2019.
Headache, Tension. (2019). In Stephens, M. B., Golding, J., Baldor, R. A., & Domino, F. J. (Eds.), 5-Minute Clinical Consult. Available from https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116255/all/Headache__Tension
Headache, Tension [Internet]. In: Stephens MB, Golding J, Baldor RA, Domino FJ, editors. 5-Minute Clinical Consult. Wolters Kluwer; 2019. [cited 2019 April 24]. Available from: https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116255/all/Headache__Tension.
* Article titles in AMA citation format should be in sentence-case
TY - ELEC T1 - Headache, Tension ID - 116255 ED - Stephens,Mark B, ED - Golding,Jeremy, ED - Baldor,Robert A, ED - Domino,Frank J, BT - 5-Minute Clinical Consult, Updating UR - https://im.unboundmedicine.com/medicine/view/5-Minute-Clinical-Consult/116255/all/Headache__Tension PB - Wolters Kluwer ET - 27 DB - Medicine Central DP - Unbound Medicine ER -